Ready for a Refresh?

If it's been a few months since you last received your CPAP supplies, it may be time for a replacement. Regular use wears out hoses, filters, straps, masks and other components, which can render treatments ineffective.

If you're an existing customer, use this form to request replacement. We'll check to validate you're eligible under your insurance benefits. If so, we'll follow up with you quickly to get your request confirmed and sent to you, ASAP! If it's not quite time, we'll let you know when you're due for replacement.

Name*

FirstLast

Customer Birthdate

Month*

Day*

Year*

Contact Preferences

How do you prefer to be contacted?*

Phone

Email

Either

Phone*

Best Time to Contact*

Email*

For contact purposes, only. We will not add you to a list or share your contact with anyone else.

Enter EmailConfirm Email

Has your insurance changed since the last date of service?

Yes

No

Not Sure

Other CPAP-Related Requests

Check any that may apply

I may need a different mask

I need help with my machine

Any Special Instructions?

Please Note: When billing insurance, customers are responsible for any deductibles or co-pay required and this must be collected before we can process the order. Our CSR will let you know of any special requirements when we contact to confirm your request.

Manual Wheelchairs

Manual wheelchairs include Lightweight folding wheelchairs as well as transport chairs. Manual wheelchairs consist of a larger rear wheel that a user can mobilize with using their arms. Transport chairs use four smaller wheels so they are smaller and easier to stow and manage and are typically used by caregivers to mobilize the user.